scispace - formally typeset

Journal ArticleDOI

Neonatal Outcomes After Elective Cesarean Delivery

01 Jun 2010-Obstetric Anesthesia Digest-Vol. 30, Iss: 2, pp 114-115

Abstract: OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.

Content maybe subject to copyright    Report

Neonatal Outcomes After Elective Cesarean
Delivery
Beena D. Kamath,
MD
,
MPH
, James K. Todd,
MD
, Judith E. Glazner,
MS
, Dennis Lezotte,
PhD
,
and Anne M. Lynch,
MD
,
MSPH
OBJECTIVE: To examine the outcomes of neonates born
by elective repeat cesarean delivery compared with vag-
inal birth after cesarean (VBAC) in women with one prior
cesarean delivery and to evaluate the cost differences
between elective repeat cesarean and VBAC.
METHODS: We conducted a retrospective cohort study
of 672 women with one prior cesarean delivery and a
singleton pregnancy at or after 37 weeks of gestation.
Women were grouped according to their intention to
have an elective repeat cesarean or a VBAC (successful or
failed). The primary outcome was neonatal intensive care
unit (NICU) admission and measures of respiratory mor-
bidity.
RESULTS: Neonates born by cesarean delivery had
higher NICU admission rates compared with the VBAC
group (9.3% compared with 4.9%, P.025) and higher
rates of oxygen supplementation for delivery room re-
suscitation (41.5% compared with 23.2%, P<.01) and
after NICU admission (5.8% compared with 2.4%,
P<.028). Neonates born by VBAC required the least
delivery room resuscitation with oxygen, whereas neo-
nates delivered after failed VBAC required the greatest
degree of delivery room resuscitation. The costs of elec-
tive repeat cesarean were significantly greater than
VBAC. However, failed VBAC accounted for the most
expensive total birth experience (delivery and NICU use).
CONCLUSION: In comparison with vaginal birth after
cesarean, neonates born after elective repeat cesarean
delivery have significantly higher rates of respiratory
morbidity and NICU-admission and longer length of
hospital stay.
(Obstet Gynecol 2009;113:1231–8)
LEVEL OF EVIDENCE: II
I
n 2006, the United States cesarean delivery rate of
31.1% was at an all-time high, making cesarean
delivery the most common surgical procedure per-
formed in American women.
1,2
This high rate of
cesarean delivery is attributed to the rise in primary
cesarean delivery rates from 14.6% in 1996 to 20.3%
in 2005, an increase of 60%.
2,3
With the rates of
vaginal births after cesarean delivery (VBAC) at an
all-time low of 7.9% in 2005, women who have a
primary cesarean delivery have a greater than 90%
chance of having a repeat cesarean delivery, only
serving to increase the overall cesarean delivery rate.
2
Almost one half of cesarean deliveries, a rate of 15%,
are done electively, before the onset of labor.
Controversy remains on whether a trial of labor
or an elective repeat cesarean delivery is preferable
for a woman with a history of cesarean delivery.
Historically, concerns regarding the increased risk of
uterine rupture and perinatal asphyxia in trial of labor
after cesarean compared with planned repeat cesar-
ean have swayed obstetricians away from recom-
mending a trial of labor after cesarean delivery;
however, the absolute risk of perinatal asphyxia re-
mains small.
4,5
By far, the most frequent complication
for the newborn after cesarean delivery is respiratory
morbidity; therefore, to avoid iatrogenic prematurity,
most obstetricians will not time the elective delivery
of an neonate before 39 weeks of gestation without
documentation of amniocentesis indicating fetal lung
maturity.
6
Furthermore, a paucity of data exists regarding
the cost of elective repeat cesarean delivery as com-
pared with other delivery options. Prior studies have
From the Departments of Pediatrics, Section of Neonatology, and Obstetrics and
Gynecology, University of Colorado School of Medicine; Department of Infectious
Disease and Epidemiology, the Children’s Hospital, Denver; and Colorado
School of Public Health, Denver, Colorado.
The authors thank Jocelyn Seelye, BS, Jan Hart, MPH, and Sarah Crowley, BA,
for being the Research Assistants for the Perinatal Database.
Corresponding author: Beena D. Kamath, MD, MPH, Mail Stop 8402,
Education 2 South, Room 4304, 13121 East 17th Avenue, PO Box 6508,
Aurora, CO 80045; e-mail: Beena.Kamath@ucdenver.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2009 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/09
VOL. 113, NO. 6, JUNE 2009 OBSTETRICS & GYNECOLOGY 1231

lacked large enough patient numbers to confidently
estimate the costs of the rare complications from each
type of delivery, therefore demonstrating a clear need
for further investigation into the costs of elective
cesarean delivery.
7,8
The aims of this study were to examine select
neonatal outcomes of neonates born by elective re-
peat cesarean delivery and VBAC in women present-
ing for a subsequent delivery after one previous
cesarean delivery, and to describe the cost differences
between elective repeat cesarean delivery and VBAC
delivery. We hypothesized that neonates born by
elective repeat cesarean delivery would have greater
respiratory morbidity resulting in admission to the
NICU, which would propel hospital costs to increase.
PATIENTS AND METHODS
We performed a retrospective cohort study using
records from the Perinatal Database of the Depart-
ment of Obstetrics and Gynecology at the University
of Colorado Denver for the period between October
1, 2005, and July 1, 2008. The study was approved by
the Colorado Multiple Institutional Review Board.
During the study period, 8,211 deliveries were re-
corded in the database. From this data set, we identi-
fied women of any parity with a history of one prior
cesarean delivery who were pregnant with a singleton
37 weeks or more gestation without congenital anom-
alies (n672). In this cohort, 343 (51.0%) planned an
elective repeat cesarean delivery, and were consid-
ered the “intended cesarean group,” and 329 (49.0%)
planned a trial of labor, and were called the “intended
VBAC group.” The intended cesarean delivery group
consisted of women who had a planned elective
repeat cesarean delivery without labor (group 1) or a
planned elective repeat cesarean delivery after onset
of labor (group 2). The intended VBAC group in-
cluded women who had successful vaginal birth after
cesarean delivery (group 3), and a failed VBAC
requiring emergent cesarean delivery (group 4). Med-
ical record review was conducted to confirm correct
classification of the category of delivery. Labor was
defined as subjectively painful contractions more
frequent than every 10 minutes, with the obstetri-
cian’s documentation of cervical change or the words
“active labor” in the chart.
The primary outcome was admission to the
NICU, defined as any length of time spent in the
NICU after delivery, and included neonates who
transitioned for a period of time due to a clinical
assessment of respiratory distress. Maternal demo-
graphic characteristics analyzed as possible confound-
ers were mother’s age, parity, race or ethnicity (non-
Hispanic white, Hispanic, African American, and
other), and maternal education (high school level or
less, university level or more). Maternal medical
characteristics included body mass index (BMI) cal-
culated using prepregnancy weight and height, his-
tory of a successful VBAC, chronic medical disease
(autoimmune disease, chronic hypertension, or pre-
existing diabetes), and diabetes during pregnancy
(both preexisting and gestational diabetes). Pregnancy
characteristics included evidence of macrosomia (ne-
onate more than 90% weight for gestational age),
attempt at amniocentesis for fetal lung maturity, in-
duction of labor, nonreassuring fetal heart tones, and
finally, chorioamnionitis (documented by the obste-
trician and defined as maternal fever plus one of the
following: fundal tenderness, purulent discharge, and
maternal tachycardia). Characteristics regarding the
neonate included gestational age (based on last men-
strual period or ultrasonography), sex, and birth
weight. Neonatal outcomes included any oxygen use
during delivery room resuscitation, highest level of
delivery room resuscitation required (routine resusci-
tation only, blow-by oxygen, mask continuous posi-
tive airway pressure, bag or mask ventilation, or
endotracheal intubation), neonate disposition (well
baby nursery compared with NICU), endotracheal
intubation outside the delivery room, hypoglycemia
requiring NICU stay, respiratory distress requiring
NICU stay (need for oxygen or other ventilatory
support), and type of ventilatory support needed in
NICU (conventional mechanical ventilation, oxygen
hood, nasal cannula, or continuous positive airway
pressure).
We obtained facility and physician charges for
both mothers and their neonates by searching the
medical invoices in the patient medical account for
the hospital days during which the delivery occurred.
We were unable to get charges for delivery compli-
cations that required readmission to the hospital.
Facility charges included those for any supplies or
facility employees (including nursing staff) needed to
care for the patient, and physician charges included
the time and services of the medical provider.
Because charges do not necessarily reflect the
actual cost of resources used to provide hospital
services and are often an artifact of accounting meth-
ods or of cross-subsidization among various hospital
services, we used costs as our measure of resource use
in this study. Costs were calculated using the Univer-
sity of Colorado hospital-wide cost-to-charge ratio of
27.79% for the births occurring before June 30, 2006,
and 28.14% for births occurring afterward. These
hospital-wide cost-to-charge ratios were lower than
1232 Kamath et al Neonatal Outcomes After Elective Cesarean OBSTETRICS & GYNECOLOGY

the actual cost-to-charge ratios for services on labor
and delivery (38.38% and 31.35%) but higher than
those for the NICU (23.72% and 20.92%) for the same
time periods, respectively. Because we did not have
more detailed lists of itemized charges, we used the
hospital-wide cost-to-charge ratio.
To report all amounts in 2008 dollars, costs were
adjusted yearly for inflation, and were also discounted
at three percent annually.
9
We adjusted for inflation
using the yearly Consumer Price Index for the years
2005 to 2008 for medical care in the Denver-Boulder-
Greeley statistical area.
10
The total amount for the
birth, including delivery and NICU use fees, was
calculated by summing the totals of the physician and
facility costs for the mothers and their neonates.
Based on preliminary analysis with a sample size
of 695, we calculated a 90% power to detect a fourfold
difference in NICU admission rates between the
intended cesarean delivery group (10%), and the
intended VBAC group (2.5%), based on a level of
significance at
0.05.
The data were analyzed using SAS 9.2 (SAS
Institute Inc., Cary, NC). Differences between cate-
gorical and continuous variables were tested using the
2
and Kruskal-Wallis tests, respectively. Multivari-
able logistic regression was used to estimate the odds
ratio of NICU admission for the three study groups
compared with successful VBAC, adjusting for the
covariates selected based on significant differences
seen in univariable analysis or after consideration
from past clinical evidence.
RESULTS
The overall cesarean delivery rate for the University
of Colorado Hospital during the time period studied
was 24.6%, with a primary cesarean delivery rate of
15.5%. Table 1 shows the general characteristics of
the four study groups. Of the 672 women included in
the study, 51% (n343) were in the intended elective
repeat cesarean delivery, and 49% (n329) were the
intended VBAC group. Of the total study population,
35.6% had a planned elective repeat cesarean delivery
without labor (n239), 15.5% had an elective repeat
cesarean delivery after onset of labor (n104), 36.3%
had a successful VBAC (n244), and 12.6% had a
failed VBAC requiring emergent cesarean delivery
(n85). We found that older women and mothers
with university or postgraduate education tended to
have elective repeat cesarean delivery without labor.
Women with successful VBAC deliveries had the
greatest parity and the highest rates of prior VBAC
compared with the other three groups. Significantly
higher rates of chorioamnionitis and nonreassuring
fetal heart tones were seen in the failed VBAC group
than in the other three groups. More amniocenteses
were done in women who underwent elective repeat
Table 1. Description of Maternal Risk Factors and Labor and Delivery Events Among Women of the
Four Delivery Categories
Maternal Risk Factors
Elective Cesarean No
Labor (n239)
Elective Cesarean
Labor (n104)
VBAC
(n244)
Failed VBAC
(n85) P*
Maternal age (y) 30.0 (21, 40) 28.0 (19, 38) 28.0 (20, 38) 29.0 (22, 38) .01
Parity 1.0 (1, 4) 1.0 (1, 3) 2.0 (1, 4) 1.0 (1, 5) .001
Race/ethnicity of mother
White, non-Hispanic 90 (38.1) 30 (29.7) 74 (30.4) 21 (24.7) .31
Hispanic 104 (43.5) 58 (55.8) 131 (53.9) 48 (56.5)
African American 30 (12.6) 9 (8.7) 22 (9.1) 11 (12.9)
Other 15 (6.3) 7 (6.7) 16 (6.6) 5 (5.9)
Maternal education
High school or less 167 (69.9) 83 (79.8) 198 (81.2) 63 (74.1) .024
University/postgraduate 72 (30.1) 21 (20.2) 46 (18.9) 22 (26.5)
Body mass index 26.4 (19.3, 41.4) 25.7 (19.3, 37.7) 24.4 (19.0, 37.8) 25.0 (19.4, 40.4) .032
Chronic medical disease
14 (5.9) 1 (1.0) 4 (1.6) 5 (5.9) .022
Had prior successful VBAC 16 (6.7) 6 (5.8) 87 (35.7) 10 (11.8) .001
Pregnancy and labor
Amniocentesis for FLM 22 (9.2) 7 (6.7) 2 (0.8) 1 (1.2) .001
Induction of labor 3 (1.3) 1 (1.0) 38 (15.6) 27 (31.6) .001
NRFHTs 13 (5.4) 11 (10.6) 31 (12.8) 21 (24.7) .001
Chorioamnionitis 4 (1.7) 4 (3.9) 10 (4.1) 14 (16.5) .001
Meconium at delivery 14 (5.9) 15 (14.4) 51 (20.9) 24 (28.2) .001
VBAC, vaginal birth after cesarean; FLM, fetal lung maturity; NRFHT, nonreassuring fetal heart tone.
Data are median (5%, 95%) or n (%).
* Continuous variables and categorical variables were compared by Kruskal Wallis and
2
analyses, respectively.
Chronic medical disease includes autoimmune disease, hypertension, diabetes.
VOL. 113, NO. 6, JUNE 2009 Kamath et al Neonatal Outcomes After Elective Cesarean 1233

cesarean delivery without labor (9.2%), as compared
with those women who had successful VBAC (0.8%,
P.001). No differences were seen in regard to race or
ethnicity, or rates of diabetes or macrosomia among
the four delivery groups.
Table 2 documents the differences seen in the
neonates born in the intended elective repeat cesar-
ean delivery and intended VBAC groups. No differ-
ences were seen in the distribution of male neonates
or birth weight between groups. For the primary
outcome, admission to the NICU, the incidence was
7.1% (n48) in the full cohort of neonates, which
included 9.3% of neonates born by intended elective
repeat cesarean delivery and 4.9% of neonates born
by intended VBAC (P.025). Our results show that
significantly greater numbers of neonates in the in-
tended cesarean group required blow-by oxygen and
continuous positive airway pressure in the delivery
room, ongoing oxygen supplementation once admit-
ted to the NICU, and higher rates of admission for
hypoglycemia. Notably, a larger number of neonates
born in the intended VBAC group required bag mask
ventilation (3.3%) and endotracheal intubation (2.4%)
in the delivery room than neonates born in the
intended cesarean group (2.3% and 0.6%, respec-
tively, P.001).
As shown in Table 3, rates of NICU admission
were similar in elective repeat cesarean delivery with
or without labor. Neonates born due to emergent
cesarean delivery after failed VBAC had NICU ad-
mission rates comparable to the elective repeat cesar-
ean delivery group, whereas neonates born after
successful VBAC had the lowest rate of NICU admis-
sion. Neonates born in either intended cesarean de-
livery group experienced significantly higher rates of
oxygen need and continuous positive airway pressure
use in the delivery room than the successful VBAC
group. However, neonates born by failed VBAC
required the most significant measures of delivery
room resuscitation, including bag or mask ventilation
and endotracheal intubation, than did the other three
groups. Neonates born by successful VBAC required
the least amount of delivery room resuscitation,
whereas neonates born by failed VBAC had rates of
oxygen supplementation similar to neonates born by
cesarean delivery.
The multivariable logistic regression analysis (Ta-
ble 4) shows that after adjustment for other covariates
(maternal education level, chronic medical disease,
amniocentesis performed for fetal lung maturity, cho-
rioamnionitis, nonreassuring fetal heart tones, and
gestational age in weeks) and compared with neonates
born by successful VBAC, neonates born by elective
repeat cesarean delivery without labor continued to
demonstrate significantly higher odds of admission to
the NICU.
After the finding that the neonates born by
successful VBAC had the least amount of respiratory
morbidity requiring NICU admission and respiratory
support, and the neonates born by failed VBAC
required the greatest amount of resuscitation and
respiratory support, we therefore performed a suba-
nalysis to identify predictors of failed VBAC. After
adjusting for maternal age, maternal race, BMI, par-
ity, chorioamnionitis, nonreassuring fetal heart tones,
induction of labor, and history of prior VBAC, signif-
icant covariates for failed VBAC were chorioamnio-
nitis (adjusted odds ratio [OR] 5.58, 95% confidence
interval [CI] 2.08 –14.99), history of prior successful
VBAC (adjusted OR 0.23, 95% CI 0.10 0.51), and
induction of labor (adjusted OR 2.53, 95% CI 1.35–
4.78). When we examined only women without a
history of prior VBAC (n204) to determine signifi-
cant covariates for the first failed VBAC, these in-
cluded induction of labor (adjusted OR 2.46, 95% CI
1.25–4.81) and chorioamnionitis (adjusted OR 4.43,
Table 2. Comparison of Neonate Risk Factors and
Neonatal Outcomes Among Women
With an Intended Cesarean or Intended
Vaginal Birth After Cesarean Delivery
Neonate Characteristic
Intended
Cesarean
(n343)
Intended
VBAC
(n329) P*
Neonate disposition
Well baby nursery 311 (90.7) 313 (95.1) .025
NICU 32 (9.3) 16 (4.9)
Neonate gestational age (wk) 39.00.97 39.51.19 .001
Oxygen during delivery room
resuscitation
142 (41.5) 76 (23.2) .001
Delivery room resuscitation
required
Routine (drying and
stimulation)
200 (58.3) 251 (76.3) .001
Blow-by oxygen 100 (29.2) 43 (13.1)
Mask CPAP 32 (9.3) 13 (4.0)
Bag/mask ventilation 8 (2.3) 11 (3.3)
Intubation 2 (0.6) 8 (2.4)
Admission for hypoglycemia 12 (3.5) 3 (0.9) .03
Oxygen requirement in NICU 20 (5.8) 8 (2.4) .028
Conventional ventilation 1 (0.3) 2 (0.6)
Oxyhood 6 (1.8) 1 (0.3)
Cannula 7 (2.0) 2 (0.6)
CPAP 6 (1.8) 3 (0.9)
VBAC, vaginal birth after cesarean; NICU, neonatal intensive care
unit; CPAP, continuous positive airway pressure.
Data are meanstandard deviation or n (%).
* Continuous variables and categorical variables were compared by
Kruskal Wallis and
2
analyses, respectively. Fisher exact test
was used in the case of a cell with n5.
1234 Kamath et al Neonatal Outcomes After Elective Cesarean OBSTETRICS & GYNECOLOGY

95% CI 1.54–12.77). Parity (adjusted OR 0.70, 95%
CI 0.53–0.92) and maternal age (adjusted OR 1.04,
95% CI 1.00–1.11) were significant covariates predic-
tive of failed VBAC.
Given the American College of Obstetrics and
Gynecology recommendations that neonates 39
weeks or younger not be delivered by elective repeat
cesarean delivery due to complications from iatro-
genic prematurity and respiratory distress, we strati-
fied neonatal outcomes by gestational age (Table 5).
The 37-week group had the highest rates of oxygen
need in the delivery room (38.8%, P.003), and
admissions to the NICU (10.0%, P.018), despite also
having a greater number of amniocenteses for fetal
lung maturity performed (25.0%, P.001) than the
older neonates. A greater proportion of the 37-week
neonates required the support of continuous positive
airway pressure (3.8%) or supplemental oxygen
(2.6%) in the NICU than the older neonates, although
this did not reach statistical significance.
The differences in length of hospital stay for
mothers and neonates and hospital costs are shown in
Table 6 and Table 7. For both mothers and neonates,
successful VBAC was associated with the shortest
length of hospital stay (median 4 days), compared
with the other three groups (median 3 days). Overall,
intended cesarean delivery was significantly more
expensive than intended vaginal delivery for both
mothers and their neonates. Both elective cesarean
delivery with or without labor accrued higher costs
compared with successful VBAC delivery. However,
facility, physician, and total costs due to failed VBAC
delivery significantly exceeded those of the other
three groups (P.001) for both mothers and their
neonates, except for neonate physician fees. Indeed,
when determining the overall costs for the total birth
(including delivery and NICU use) presented as me-
dian followed by 5% to 95%, the failed VBAC group
was the most expensive ($9,388, 6,631 to 16,275),
followed by elective cesarean delivery with labor
Table 4. Multivariable Logistic Regression Models
Showing the Unadjusted and Adjusted
Odds Ratio of the Categories of Delivery
and Select Covariates for Admission to
the Neonatal Intensive Care Unit
Unadjusted
OR
Adjusted
OR 95% CI* P
ERCD, no labor
2.78 2.93 1.28–6.72 .011
ERCD, with labor
2.47 2.26 0.85–6.00 .100
Failed VBAC
2.34 1.91 0.66–5.58 .235
Successful VBAC 1.00 1.00
OR, odds ratio; CI, confidence interval; ERCD, elective repeat
cesarean delivery; VBAC, vaginal birth after cesarean.
* Values of 95% confidence interval and P are for the adjusted odds
ratio.
Successful vaginal birth after cesarean as referent.
Table 3. Comparison of Neonate Risk Factors and Neonatal Outcomes by Four Study Groups
Neonate Characteristic
Elective Cesarean
No Labor (n239)
Elective Cesarean
Labor (n104)
VBAC
(n244)
Failed VBAC
(n85) P*
Neonate disposition
Well baby nursery 216 (90.4) 95 (91.3) 235 (96.3) 78 (91.8) .068
NICU 23 (9.6) 9 (8.7) 9 (3.7) 7 (8.2)
Gestational age (wk) 39.1 (37.0, 41.0) 39.1 (37.3, 41.0) 39.5 (37.4, 41.3) 40.0 (37.4, 41.4) .001
Male sex of neonate 122 (51.5) 59 (56.7) 123 (50.4) 46 (54.1) .70
Birth weight (kg) 3.3 (2.7, 4.2) 3.3 (2.5, 4.1) 3.3 (2.6, 4.0) 3.3 (2.6, 4.0) .11
Oxygen during delivery room
resuscitation
96 (40.2) 46 (44.2) 46 (18.9) 30 (35.3) .001
Most delivery room resuscitation needed .001
Routine 142 (59.4) 58 (55.8) 196 (80.3) 55 (64.7)
Blow-by oxygen 66 (27.6) 34 (32.7) 27 (11.1) 16 (18.8)
Mask CPAP 22 (9.2) 10 (9.6) 13 (5.3) 0
Bag/mask ventilation 6 (2.5) 2 (1.9) 3 (1.2) 8 (9.4)
Intubation 2 (0.8) 0 3 (1.2) 5 (5.9)
Admission for hypoglycemia 9 (3.8) 3 (2.9) 2 (0.8) 1 (1.2) .14
Oxygen requirement in NICU 14 (5.9) 6 (5.8) 3 (1.2) 5 (5.9) .04
Conventional ventilation 1 (0.42) 0 0 2 (2.4)
High frequency ventilation 0 0 0 0
Oxygen hood 5 (2.1) 1 (1.0) 0 1 (1.2)
Cannula 6 (2.5) 1 (1.0) 1 (1.2) 1 (1.2)
CPAP 2 (0.8) 4 (3.8) 2 (0.8) 1 (1.2)
VBAC, vaginal birth after cesarean; NICU, neonatal intensive care unit; CPAP, continuous positive airway pressure.
Data are n (%) and median (5%, 95%).
* Continuous variables and categorical variables were compared with Kruskal Wallis and
2
analyses, respectively.
VOL. 113, NO. 6, JUNE 2009 Kamath et al Neonatal Outcomes After Elective Cesarean 1235

Citations
More filters

Journal Article
TL;DR: For most women fearing childbirth, proper therapy will encourage them and abandon their wish for cesarean section and encourage them to be forced into vaginal delivery.
Abstract: Fear of childbirth casts a shadow in 10% of the pregnancies. It can cause fear, mental illnesses and previous experiences of violence or bad experiences in giving birth. It is treated at the phobia clinic with the support of a midwife and an obstetrician. Psychoeducative group therapy intended for primigravid women has proven to be the most effective form of therapy. In addition to obstetric assessment, its cornerstones include hearing and supporting of the phobic patient. For most women fearing childbirth, proper therapy will encourage them and abandon their wish for cesarean section. Nobody should, however, be forced into vaginal delivery.

92 citations


Journal ArticleDOI
Howard Blanchette1Institutions (1)
TL;DR: To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications.
Abstract: Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children.

87 citations


Journal ArticleDOI
Rohan D'Souza1Institutions (1)
TL;DR: The reasons behind the increase in CSMR are explored, various guidelines are discussed and the current published research is reviewed, including the risks, benefits, controversies, cost and ethics surrounding CSMR.
Abstract: The past decade has seen an unprecedented rise in the demand for caesarean sections on maternal request (CSMR), in the absence of any medical or obstetric indication. Much of this rise is the result of the perceived myth of safety of caesarean sections and the changing attitudes of society and the medical profession to childbirth. The debate on the medical, ethical and cost implications of rising rates of caesarean section on maternal request have prompted the issuing of numerous guidelines over the past few years, including one by the National Institute of Health and Clinical Excellence (NICE) in the UK. All these guidelines are uniformly less critical of CSMR than guidelines issued even a decade ago, and suggest valid management strategies. In this chapter, I explore the reasons behind the increase in CSMR and review the current published research, including the risks, benefits, controversies, cost and ethics surrounding CSMR. I then discuss various guidelines, putting the NICE guidelines in perspective.

55 citations


Journal ArticleDOI
TL;DR: The factors responsible for the increase in CDMR rates are explored, the safety and cost implications of CS are assessed, and the recent guidelines and recommendations on CDMR are reviewed.
Abstract: The last few decades have seen an unrelenting rise in caesarean section (CS) rates. In addition to an increase in numbers of CS performed worldwide, there has also been a change in the indications for CS, a reflection of changing times. A new dilemma facing obstetricians is the increasing demand for CS in the absence of any medical indication (caesarean delivery on maternal request - CDMR). The paucity of evidence either in favour or against, the poor understanding of long-term health and financial implications and the complex ethical issues surrounding CDMR make counselling extremely challenging. Needless to say, CDMR has generated enormous interest both in the media and among health-care providers, and many national and international bodies have now issued guidelines on the topic. In this editorial, we have aimed to explore the factors responsible for the increase in CDMR rates, assess the safety and cost implications of CS and review the recent guidelines and recommendations on CDMR.

52 citations


Cites background from "Neonatal Outcomes After Elective Ce..."

  • ...Neonatal respiratory morbidity When compared with spontaneous vaginal deliveries, neonates born after elective CS have signifi cantly higher rates of respiratory morbidity, neonatal intensive care unit (NICU)-admission and longer length of hospital stay [45, 56] ....

    [...]


Journal ArticleDOI
Ravi Mangal Patel1, Lucky Jain1Institutions (1)
TL;DR: Observational studies suggest an increased risk of perinatal mortality and hypoxic-ischemic encephalopathy in infants whose mothers undergo a trial of labor and further studies are needed to identify potential strategies to improveperinatal outcomes.
Abstract: Women must often choose between a vaginal birth after previous cesarean and elective repeat cesarean delivery. Short-term risks of vaginal birth after cesarean can be potentially catastrophic in the setting of uterine rupture. Although randomized controlled trials comparing these 2 modes of delivery are lacking, observational studies suggest an increased risk of perinatal mortality and hypoxic-ischemic encephalopathy in infants whose mothers undergo a trial of labor. These rare risks compete with more common, albeit less severe, short-term risks associated with elective repeat cesarean delivery, with a particular emphasis on increased respiratory morbidities. Further studies are needed to identify potential strategies to improve perinatal outcomes and help guide physicians and patients in choosing optimal methods of delivery.

48 citations


Performance
Metrics
No. of citations received by the Paper in previous years
YearCitations
20181
20178
20162
20155
20141
20139